a guest post by Keith McCullough

The economics of healthcare are complex, even within a single country. When making comparisons across countries, “How many poor people are there?” – is a difficult question, let alone what we’re really interested in: “How does poverty impact access to healthcare?”

Who is poor? How many poor people are there? The World Bank uses the purchasing power parity (PPP) statistic to address these problems. This statistic ‘translates’ the value of someone’s wages into a ‘standard’ basket of goods. Of course, there are difficulties with this approach. Prices for various goods can vary wildly depending on local circumstances, or whether the particular good is imported. Each item in the basket may need to be ‘translated’ to a local equivalent (e.g. a bag of rice instead of a bag of flour). The World Bank has described some of their efforts along these lines, including the need to consider urban v. rural, changes in value over time, and lack of data due to turbulent local conditions.

The PPP is a reasonable metric for their purposes, but healthcare is not an easily-described ‘good’ with a well defined ‘price’. In many countries, including countries with universal healthcare (which is not the same as single-payer!), payment for a medical treatment or procedure can involve a combination of public insurance, private insurance, and ‘out of pocket’ costs. These costs might be calculated for each service, or bundled together into a single overall payment, which may make it nearly impossible to assign a single ‘price’ to a specific procedure.

Even if we had a good set of healthcare procedures with well-defined costs, examining financial barriers to healthcare access is more complex than just translating someone’s income into a ‘healthcare’ PPP.

Income alone isn’t enough information: A retiree with very low income might have good public and/or private insurance, and thus very good access to healthcare.

Wealth + income isn’t enough information: Many procedures are simply outside the purchasing power of the vast majority of the population, which is why we have insurance.

Wealth + income + insurance isn’t enough information: Our ‘healthcare’ PPP is extremely sensitive to location (it’s hard to ‘ship’ healthcare). For example, pregnancy ultrasounds cost over four times higher (on average) in Alaska than in Arizona. Many procedures and treatments are simply not available in some countries at any reasonable cost, due to lack of infrastructure, patent issues, or other reasons.

Wealth + income + insurance + location isn’t enough information: Even if a procedure is completely covered by some sort of insurance, and you live in an area where the procedure is available, there may still be long wait times for some procedures (e.g. hip replacement). Wait times limit access to the people who survive the wait. In many countries with universal healthcare, citizens who are capable of doing so will purchase additional insurance to improve their access (via decreased wait times), or go to other countries for procedures, but sometimes this is not an option. Someone’s access to a procedure depends on what everyone else is doing, not just their own resources and location.

Just to be clear: my description of the difficulties in comparing international data is not an attempt to rationalize away international comparisons that indicate that US citizens have generally low access compared to other first-world countries. I favor increased healthcare coverage, mainly because current research shows that increased coverage saves lives, e.g. through early detection of serious conditions. I also like the fact that increased coverage reduces the unfairly high prices poor people tend to pay for the same procedures. This article is simply describing the fact that this is a complex issue that researchers have been working on for some time.

Melal just wanted to escape the maltreatment of enhancers, but found herself protecting deluded girls who believed that it was a good idea to go to war to end religious persecution. The magical ability Melal had to enhance led her to a mission for a god with the help of an attractive stranger. The god promised a reward if they succeeded but didn’t promise either of them would live to collect it.

1. I went to a bank in a grocery store to close a certificate of deposit. I was told they didn’t do that there and was sent to another branch.

2. I tried to update my soon-to-be-expired credit card at my gym and the manager-on-duty told me she didn’t do that.

3. We came into a restaurant and I requested that we have a table near the front door because my husband, who walks with a cane, wanted to minimize the distance he walked. She took us to a table at the far end of the restaurant, passing many empty tables.

In all three cases, I quietly complained. The other branch of the bank and a manager-on-duty at another time in the gym both told me that the person I talked to should have done what I asked. The manager at the restaurant said that we should have been given our choice of table.

The person who seated us at the restaurant was particularly puzzling. It would not take any more effort to seat us closer to the door. When we were about two steps from the table, I complained to her and she asked if we wanted to go back to another table. I hope she misunderstood my request, because otherwise she was malicious. I presume the other two people simply wanted to pass along the work to someone else.

I hope in all three cases the person received appropriate criticism from their bosses. If this was a pattern of behavior, they should have been fired. Perhaps others don’t complain. They should.

Melal was an enhancer, which meant she had the ability to do magic. She lived in an area where enhancers were harassed and persecuted. As things got worse she decided to leave, joining a woman named Nefance whose wagon offered her a quick way out of town. What she didn’t realize was that Nefance was with a group that intended to start a war.

Tekad was unfairly thrown out of his home because of the treachery of Nefance, the woman who raised him. As a homeless vagabond, he met Nefance again, along with Melal.

Tekad wanted nothing to do with the war, but Melal was attractive and she wanted to save a group of deluded girls who were all enhancers and thought that they were doing a wonderful thing to help the war. In both war and peace, Tekad and Melal found that caring for young enhancers was both dangerous and rewarding.

As usual, the week before classes start, we had meetings. Some of presentations at these meetings are designed to help us teach better. In one meeting, the speaker said that for teaching math, the students should have lectures for only a third of the time. The rest of the time they should be actively working, instead of passively listening. He actually had us actively working now and then for a minute or two. I didn’t time these sessions, but it was between five and ten percent of the total time.

If a class runs for 100 minutes, they schedule it for 110 minutes and tell us to give the students a ten minute break. Meetings often run longer than that in practice, and in theory one speaker was scheduled for two and a half hours without a break. Do they really think we have that long an attention span?

Most speakers had good Power Point slides that were legible, but when I have sat in the back of the room, some speakers have slides I can’t read. A speech teacher I know once said that any visual aide should have two characteristics: people should be able to see it and it should help. We had some in the meetings that were too long to read without ignoring the speaker. What do they think they are accomplishing? Do they wish to be ignored? Or, do they want us to be impressed when they put long paragraphs on the screen?

If these speakers believed what they said, we would have very different meetings.

Two recent incidents in Intermediate Algebra (high school Algebra II) help explain the low pass rates of students.

In the first case the student was trying. He was supposed to be working on an online assignment which involved factoring of trinomials. I saw he had another screen up and asked him about it. He said he was working, which was true. He Googled the factors of 45.

In the second case, the student arrived fifteen minutes late to a computer classroom, where beverages are not allowed, carrying a cup of Starbucks coffee. When I reminded him of the rule, he put his coffee cup next to the wastebasket. I threw it away after he left without it. This would not be a particularly significant incident except the fifteen minutes he missed of class was from a test which was 16% of his grade.

These two incidents display the major reasons students don’t pass, lack of prerequisite knowledge and lack of commitment.

The last line in an article from The Washington Post was a quote from a Chinese official: “The habit Chinese students have formed is that they only memorize things but not absorb them. They forget about everything once the test is over.”

Most people think tests are there to measure students’ progress. That is not the only reason for tests, but some think it is.

The measurement of progress is reported to many people:

1. The student. This is often skipped in standardized tests designed to measure the teachers or the schools more than individual students, but the tests that are most important to the student should be reported to him.

2. The student’s parents. Obviously, this step should be done only if the student is a minor.

3. The teacher. Usually, the teacher grades the test, but with electronic and standardized testing something else grades the test. As a teacher, I’ve often used test and quiz results to modify reviews for the final exam and to change the emphasis the next time I teach a course.

4. Where the student goes next. This could be a job or simply the next semester’s course. Usually, the report is only a single grade.

5. Society. This helps judge the quality of the teacher of the school. It rarely names individual teachers or students.

A second goal of tests is to help student learning. Students often think they know a subject until they are tested on it. If the student doesn’t get feedback, ideally quickly, that student will have difficulty learning. How the students use the results of the test often determines how well he does in school. Graded homework, quizzes, and tests give the students an idea of how much they know. If they only study to do well on tests and forget about it afterward, they are not studying properly. Their actual learning will be incidental, not the goal of the work they are doing.

Unfortunately, American students have formed the same habits as Chinese students. If we want any real progress in education, students need to know things after they take their tests.

Some people are too sensitive. Someone described an incident where a child was backing up with a shopping cart and when she said “Watch out,” the mother complained she was rude. She could have said, “I am walking behind you. If you back up, back up without looking, you may be hit by my cart. Please be careful.” By the time she said that, the damage might be done.

It is more important to issue warnings promptly than politely. Rudeness rarely accomplishes what one wants it to. Most people are not going to think, “He was rude. I deserved it.” They are going to stop at the first sentence.

In this day and age of crazy people, I try to be polite to all strangers, because I certainly don’t want to offend someone who may decide to retaliate. That may sound paranoid, but it would only be paranoid if I dwelt on it. When I force myself to be polite in situations where rudeness seems justified, I almost never make the decision based on fear. I don’t think that people may be crazy, only that I’ve decided to try to be polite. It’s like buckling seat belts. I almost never think in terms of potential accidents, just that I should buckle them. Unlike seat belts, routine politeness brings more immediate positive results than buckling seat belts. People tend to be nicer to me.